I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.
Our guest today is Reub Strayer
(@emupdates). He is the author of EMUpdates.com. His research and clinical interests include checklists and standardization, airway, legislative work on the treatment of opioid dependence, and an approach to opioid misuse in the ED.
Reub breaks agitated patients down in to 3 groups:
1. Agitated, but Cooperative
Not a problem in the ED. Oral medications or non-pharm techniques.
2. Disruptive without Danger
Use standard anti-psychotics and sedatives, with the understanding that Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation. There are better choices for this group:
- Droperidol monotherapy 5-10 mg IM or 5 mg IV
- Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe
- Olanzapine 10 mg IM (Needs Resp Monitoring)
- Olanzapine 5 mg + Midazolam 2 mg IM or IV (Needs Resp Monitoring)
- Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)
If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group.
3. Disruptive and Dangerous
- dangerous to staff, dangerous to self
- danger is relative to the resources of the location
Danger could be due to
- The agitation itself or
- An underlying condition that the agitation is preventing from being treated (and may be the cause of the agitation, e.g. tension pneumothorax)
Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test.
Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation)
Intramuscular Medication Administration
- Can go through clothes if you need to [Fleming et al.]
- Reub states maximum volume of up to 20 mls per injection
Ketamine Brain Continuum
Selected References
- Cole, Jon B., Johanna C. Moore, Benjamin J. Dolan, Alex O’Brien-Lambert, Brandon J. Fryza, James R. Miner, and Marc L. Martel. “A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department.” Annals of Emergency Medicine 69, no. 3 (March 2017): 327-336.e2. https://doi.org/10.1016/j.annemergmed.2016.08.008.
- “Intravenous Midazolam-Droperidol Combination, Droperidol or Olanzapine Monotherapy for Methamphetamine-Related Acute Agitation: Subgroup Analysis of a Randomized Controlled Trial – PubMed.” Accessed August 30, 2020. https://pubmed-ncbi-nlm-nih-gov.eresources.mssm.edu/28160494/.
- Khorassani, Farah, and Maha Saad. “Intravenous Olanzapine for the Management of Agitation: Review of the Literature.” The Annals of Pharmacotherapy 53, no. 8 (2019): 853–59. https://doi.org/10.1177/1060028019831634.
- Martel, Marc L., Lauren R. Klein, Robert L. Rivard, and Jon B. Cole. “A Large Retrospective Cohort of Patients Receiving Intravenous Olanzapine in the Emergency Department.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 23, no. 1 (January 2016): 29–35. https://doi.org/10.1111/acem.12842.
- Podcast 060 On Human Bondage and the Art of the Chemical Takedown
- Podcast 185 Disruption, Danger and Droperidol by Reub Strayer
Updates
Friend to the Show, David Barbic, did a prospective trial demonstrating Ketamine is better than haldol/midaz for rapid agitation control. All those who use ketamine knew this already but we need studies like this for the doubters. [10.1016/j.annemergmed.2021.05.023] none of these pts got intubated despite the completely flawed Cole data (no fault of Dr. Cole–ask me if you want to understand.)
Additional New Information
More on EMCrit
- Podcast 060 – On Human Bondage and the Art of the Chemical Takedown
- Podcast 185 – Disruption, Danger and Droperidol by Reub Strayer
Additional Resources
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Thoughts on nasal route? Kinetics of IM are definitely better studies, but in a potentially violent situation this removes the needle entirely. Seems like an attractive option.
I want to be nowhere near these pts’ faces
Excellent advice. Have had to stand by ( though not quietly) as ER resident gave Ketamine to a y/w/f who occasionally presents acting psychotic/suicidal. Her agitation ramps if not given the medications she states is needed. Problem is she has demonstrated h/o asthma and stated problems with anesthesia. She could be given any IM/IV and she’d become happy/compliant and sent on to inpatient psych. We tied up three rotating RNs half a 12 hour shift 1:1 with her on a Friday night, when a little droperidol/midozolam had worked several times in past. She could not be moved from ED till… Read more »
absolutely, huge pain in the butt for no gain
What about ziprosidone (geodon)?
haven’t found it to be rapid–I use it for ICU delirium
Excellent podcast and general summary of this important topic. One point regarding your cocktails for the “Disruptive Without Danger” group — I think it’s worth noting that there is a warning about coadministration of IM Olanzapaine with parenteral benzodiazepines. The packaging insert says it hasn’t been studied (though this is no longer true) and that therefore it is not recommended and that if you do it, you need to look out for complications such as respiratory depression. Obviously we are all able to manage respiratory depression, and several studies have looked at this specific question with mixed results but certainly… Read more »
all our pts receive ETCO2 waveform for the duration of their sedation for this specific reason and they are all on 1:1. If you don’t have the resources for those 2 things, then droperidol is probably a better choice as resp depression can occur even with olanzapine as a single agent.
Any advice on getting droperidal on formulary? Lots of resistance here to even trying.
I believe Olanzipine and Ativan together parenterally have a black box warning. This may also apply to other benzodiazepines. Also consider that IV Olanzipine and IV Haldol are both “off label”. I use both, but get push back from staff. Hope to get droperidol back again, but really have had good results with IV Olanzipine.
Dexmedetomidine 0.025% nasal spray is a new option for self administration in agitated patients. It can take 30 minutes to work so the earlier it can be given eg by paramedic or triage the better. No respiratory depression, induces a natural sleepiness and reduces catecholamines so caution required in patients that depend on sympathetic nervous system tone. Ketadex nasal spray 12.5/25 steps up the sedation and analgesia also without respiratory depression and would also benefit agitated patients. These nasal sprays are used as premedications for procedural sedation.
5 & 2 is the Sex Panther of agitated patient management. 60% of the time, it works every time.
Thank you for this podcast. I found it hugely useful. As a Paramedic I recently taught the 4 C’s to consider when choosing whether to sedate the disruptive pt who is not causing harm. Define and treat the CAUSE? Are they deemed COMPETENT? (I am happy to let a patient who is simply being belligerent and is not at risk, leave my presence), What is the likely clinical COURSE post sedation?, Plan for the CONSEQUENCES. Thoughts on this would be welcome:)
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Any chance of getting a citation on the safety of a single 10ml bolus in the thigh? I couldn’t find any research to back up Dr. Strayer’s statement, but it would be wicked useful. Our ketamine is 50 mg/ml, so 10 ml needed to chemically restrain a big guy.
Same, he mentions in the episode that he is aware of multiple studies but I have been unable to find any. Thanks, excellent episode.
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Super. Thanks for posting the citations!
Why does Lorazepam persist as the acute “takedown” BZD in acute agitation? We’ve proven time and again that Midazolam is far faster absorbed and effective.
I have used Ketamine, and in some patients even a hefty dose of 100mg seems to have no effect. Is there any information about patients with resistance or tolerance to this medication or are there any alternative drugs recreational or prescriptive that block its effects?
Our prehospital protocol uses a dissassociative dose of 4.0 mg/kg. That’s 300 mg for a 75 kg person. I’d suspect 100 mg of ketamine would be too low to work.
Sorry for the lame post, but the CME for this podcast is not coming up in My Courses. Has it been released for this episode? By the way, thanks for this. I am much more deliberate about the sedating agents I use for my agitated patients now.
It has indeed, try emptying your cache in browser–if still not working, send us a screen shot at emcrit.org/help
Great podcast and excellent classification for patients for pre-hospital as well. Not all pre-hospital patients are excited delirium. Great to be able to have Droperidol back in formulary. Ketamine is effective when needed but not for every sedation. Thank you
Great post. The intervention I see missed is the follow-up treatment once the Ketamine (or Droperidol or Midazolam ) is starting to wear off. Amphetamine use precipitates many of our Severe Behavioural Disturbance incidents. Given the half life of Amphetamine is 10-12hrs and the agents we are using to control it half life is <90mins I would often follow up with a longer acting agent (e.g. 10mg IM Olanzapine ) before the patient becomes alert. The half-life of Olanzapine and most Amphetamines is pretty similar and, whilst the patient takes a bit longer to become sharp it seems a lot… Read more »
These pts often wake up from the ketamine markedly better. Droperidol is fairly quick acting so you can definitely wait and see how they wake up. I often will give them 5 of drop before they wake up and see from there. Problem with Olanzapine is it is sedating and long-acting. Sometimes it knocks them down too far to get out of your department.